摘要:依據聯合國愛滋病組織(UNAIDS)發表的最新報告顯示愛滋病毒(HIV) 感染人數逐年創新高,截至2013年為止,現今全球人類免疫不全病毒(human immunodeficiency virus,簡稱HIV) 的感染者約有3,530萬 (3,220萬~ 3,880萬),亞洲地區(東亞及東南亞)則約有478萬(355萬~ 640萬),而每天約有6,200名新感染者產生。其中性行為與毒品是最主要的感染途徑,全球男女感染比率目前已趨近1:1,因懷孕導致小孩垂直感染的案例日增,亦即可能有更多愛滋寶寶將由母親處感染到愛滋病毒。約翰霍普金斯大學彭博公共衛生學院(Johns Hopkins Bloomberg School of Public Health)教授尼爾森(Kenrad Nelson)指出,接受抗反轉錄病毒療法的人數已有大幅增加,新的感染案例持續減少,愛滋死亡率也不斷在下降,愛滋疫情高峰期已經成為過去式,但是「邁向零愛滋」(Getting to Zero)的「零成長、零歧視、零死亡」願景,仍因為某些因素而遇到阻礙。MSM導致的愛滋感染,在許多國家日益嚴重,樂觀的治療心理、歧視的存在(降低篩檢及治療的意願)、性邀約的管道(如網路)增加、助興藥物的使用,都助長了MSM感染愛滋的風險。防止愛滋疫情擴大的另一項難題在於俄羅斯、東歐及中亞等許多國家有嚴重的靜脈藥癮者(IDUs)問題,但政府沒有提出因應辦法,這些國家正好是目前全球僅剩的幾個愛滋疫情仍在持續惡化的地區。將藥癮者視為病患而非犯罪者,有助於控制愛滋疫情。另外,性活躍的異性戀族群,包括非洲南部的已成年青年以及未成年少女,還有其他各地的性工作者,也都是控制愛滋疫情的漏洞。世界衛生組織將103年世界愛滋病日主題訂為「Close the gap」,就是希望能朝消弭各項愛滋預防、治療及照護上的障礙而努力,讓大家都能有機會且無差異的接受到完善的醫療照護。我國愛滋防治策略近年成效顯著,截至103年8月底止感染者就醫人數計20,477人,就醫率達87.17%,且新通報個案3個月內就醫率達91.58%;服用抗愛滋病毒藥物之患者近80%均能規律回診,服藥一年後病毒量亦大幅降低,顯見規律治療成效良好,相對也呼應「Close the gap」的目標。102年9月台北國際愛滋病研討會以「逆轉愛滋,從我做起」為標語,就是希望疫情控制能「從我開始」,希望民眾保護自己也保護別人。特別強調「個人責任」的重要性,無論是認識愛滋的民眾,或是愛滋感染者本身,在愛滋防疫的工作上,個人都必須承擔更多的責任。疾管署指出,2008至2012年間,感染愛滋的男性約有四分之三是因為男性間性行為(MSM)而感染。年輕人性生活活躍,其中又以MSM為主要感染途徑,1984年至2012年為止,15至24歲的感染者占了18.5%。依疾管署資料統計,201)年愛滋感染者平均年齡為31.0歲,為自1991年以來平均感染年齡新低,其中15歲至30歲感染者也從2007年的795人上升至1301人,最年輕的感染者僅16歲,顯示愛滋感染年輕化。一直以來的愛滋病毒傳染途徑90%係經由性行為傳染,毒品施用者因共用針具注射行為造成愛滋病毒感染長久以來為個位數,但自民國92年毒癮者感染人數首次突破十位數達74人,至96年6月已累積至5,488名,佔總感染人數38.94%,顯示疫情逐漸飆升,面對此一新挑戰,幸賴行政院核定「愛滋病減害計畫」以因應毒癮愛滋個案的遽增,94年8月由台北市、台北縣、桃園縣、台南縣進行「毒品病患愛滋減害試辦計畫」;並於95年7月起擴大辦理清潔針具計畫,全國23縣市共計設置清潔針具及愛滋衛教諮商輔導站427處;於95年8月擴大辦理替代療法計畫,全國22縣市設置替代療法醫療執行機構,使得毒品注射群體愛滋病盛行率顯著下降,但男同性戀族群間的愛滋病毒感染率仍然每年新增比例都超過15%。再者,台灣與東南亞國家和中國大陸等高感染盛行率地區的交流頻繁,更加速HIV感染的擴散。政府於79年11月30日經立法院三讀通過「後天免疫缺乏症候群防治條例」,同年12月17日由總統公布實施,中間歷經數次修訂施行細則以符合實際需求。90年年底衛生福利部疾病管制署(前行政院衛生署)為有效推動愛滋病防治計畫,減少感染人口,維護國人健康和確保青壯人口生產力,以防範愛滋病流行造成社會和經濟動盪,故凝聚各部會之力量共同推動,以統籌落實各項因應措施,特別設置了「愛滋病防治推動委員會」,將愛滋病防治提昇至中央跨部會之層級。為確保對愛滋病防治的重視,行政院承諾將愛滋病防治經費列為國家預算優先編列項目,加強跨部會協調與合作,盡一切努力,積極推動防治工作,全面對抗愛滋病漫延。台大醫院充分瞭解政府相關單位打擊愛滋病的決心,故結合本院與北區熱心同仁一起籌組「愛滋病防治中心」,以全體之力與政府共同對抗愛滋病帶來的挑戰。「人類免疫缺乏病毒傳染防治及感染者權益保障條例」部分條文修正草案,103年4月3日經行政院第3392次院會決議通過,將送請立法院審議。此次修法,將為我國愛滋防治政策與國際社會之接軌開創新頁。衛生福利部疾病管制署表示,此次修法重點在於取消非本國籍感染者之入境及停居留限制,與國際人權趨勢接軌。另調整感染者醫療費用由公務預算支應之原則,以符合愛滋病已經成為慢性疾病之現況,將感染者醫療費用調整為防疫為重的「醫療轉銜期」由公務預算補助,維持為重的「治療維持期」回歸健康保險給付。修正草案中另一重點為考量醫療之必要性或急迫性,增訂無需取得受檢查人或其法定代理人同意,即得採集檢體進行愛滋病毒檢測之情形,俾利進行預防性投藥評估及後續治療等相關醫療處置。台大醫院「愛滋病防治中心」於86年6月間成立以來,全體同仁積極參與防治與臨床工作,陣容愈來愈強化,不但責無旁貸地照護住院病患,亦主動且積極地派遣醫護人員前往各家醫療院所支援。本中心18年來在衛生福利部疾病管制署(前行政院衛生署)大力資助下已達到初期的成果,不論是臨床醫療服務或是研究工作皆成果豐碩,在人事訓練及佈局都已漸穩定,中心實驗室已稍具規模,將踏實地邁入繼往開來承先啟後的關鍵期。我們責無旁貸將繼續擔負起愛滋病防治與醫療的重要責任,所以向衛生福利部疾病管制署提出申請「愛滋病防治中心」105年度計畫,因為愛滋病毒的傳播涉及社會文化、性行為改變,實是一社會改造運動,而非單純醫療衛生問題,所以除了愛滋病醫療照護外,本中心將結合教育、文化、社會各體系共同合作推動防治計畫,尤其注重教育訓練,預定將以本中心及北區各個醫院之現有資源,開辦一系列衛教課程及研討會,因為普及防治教育和宣導,是打破HIV感染惡性循環的最佳方法。我們體認到愛滋病不僅是致命疾病,更嚴重影響社會發展、減低生產力、讓外資怯步、降低人民生活水準,甚至削弱政府與社區力量。本中心的全體醫護同仁將提供愛滋病病患最適當的抗病毒藥物和伺機性感染藥物治療,每年更新用藥的準則,另外討論檢驗項目及間隔時間,訂定檢驗項目的原則,讓臨床醫師在照顧病患時有所遵循,並力行節約健保資源,研究更為經濟之治療方式來造福愛滋病患者,並強化照護系統,使病患、家人和其社區都能獲得適當的支持。自73年通報第1例愛滋病毒感染者以來,截至104年7月累計本國籍通報個案數為30,054人,其中存活個案數為25,164人,約佔通報個案之83.73%。自抗愛滋病毒雞尾酒療法(HAART,Highly-Active Anti-Retroviral Therapy)治療問世以來,感染者生活品質提高,存活時間大大延長,但存活之感染者將日益增加,新感染者仍不斷產生的情形下,與感染HIV相關醫療問題,如相關合併感染症、治療副作用及抗藥性等醫療照護問題,需持續透過相關臨床研究與監測及醫事人員培訓與教育等,以提升治療成效與照護品質,並加強感染者衛教諮詢服務及行為介入措施,以避免其感染他人。本計畫內容包含研究不同易感族群以不同雞尾酒療法藥物治療,以及保險套使用等預防感染措施因素,分析出具有意義之醫療照護模式以及有效之預防介入措施;評估愛滋病毒體液暴露後預防性用藥(post-exposure prophylaxis, PEP)之可行方案與效益等;藉由其研究及應用過程,培訓相關專業醫療、臨床、研究人才,提升愛滋相關實驗室及臨床研究質量。為提昇及結合全國愛滋病指定醫院醫療資源及感染者相關資料,進行全國性跨醫院之HIV臨床流行病學相關研究,協力從事包括了解國內感染者臨床特徵、伺機性感染治療與預防、就醫意願、高危險行為、治療之抗藥性及副作用等相關臨床流行病學研究,以供後續治療與防治相關政策制定與修訂之參考。另「愛滋病防治中心」應扮演領導國內治療與防治相關之角色,應有相當之資源規劃教育訓練及建置並執行Post Exposure Prophylaxis (PEP)等項目。「愛滋病防治中心」105年度計畫的實施重點如下列:總計畫名稱:愛滋病防治整合型研究計畫─愛滋病防治中心研究重點:愛滋病防治之相關措施及治療照護與專業醫療人力培訓應用研究研究目標:藉由調查及實驗室分析不同之易感族群之醫療利用特性,結合全國愛滋病指定醫院協力從事愛滋病防治相關流行病學與臨床治療研究、監測、專業人員培訓及感染者預防計畫,以發展更佳之醫療照護及防治之介入模式,提供健全愛滋病醫療照護及防治策略之建議。研究內容:主題1.愛滋病毒體液暴露後預防性用藥(Post-exposure Prophylaxis):提供衛教諮詢、檢驗、預防性投藥與追蹤等服務,並評估其治療成效以及於高風險族群進一步推廣之效益與可行方案。主題2.研究國內HIV感染者的臨床病徵、藥物治療成效、副作用、伺機性感染處置、就醫行為與高風險行為等長期臨床研究與監測。主題3.分析不同易感族群接受HAART治療、預防性投藥或保險套使用等預防感染措施之相關因素,改善相關醫療照護模式及發展有效之預防介入措施。主題4.蒐集並監測愛滋病毒感染者合併感染症、抗藥性、基因亞型等相關流行病學與HAART血中濃度等臨床檢驗資料。主題5.辦理醫事人員愛滋病治療照護及全面性防護措施等相關在職訓練課程至少2場、專題研討會至少15場。
Abstract: The latest report presented by the Joint United Nations Program on HIV/AIDS (UNAIDS) showed a new record high in the population of HIV infections. As of 2012, 34 million people were living with HIV/AIDS, and among which 23.5 million people are in sub-Saharan Africa. Some 14.8 million people require medical treatment, but only 8 million people have availed of proper treatment. It was also noted that sex practices and prohibited substance use are the essential routes of infection. The global gender ratio of people living with HIV/AIDS is now gradually approaching 1:1 since cases of direct infection of fetus during pregnancy are also gradually rising. It is therefore possible that more babies may be born with HIV infection by their mothers. According to Professor Kenrad Nelson of the Johns Hopkins Bloomberg School of Public Health, there have been a huge increase in the number of patients undergoing the Antiretroviral Therapy, and the number of new HIV infections is continuing to decrease; moreover, the fatality rate of AIDS is also on a continuing decline. The AIDS epidemic peak period has come to past; however, the “zero growth, zero prejudice, and zero fatality” objective of the Getting to Zero campaign continues to bump into walls due to the influence of certain factors. MSM related HIV infections are still worsening in many countries. Optimistic therapeutic mentality and prevalence of prejudice (declining the inclination for screening and medical treatment), increase of sexual invitation channels (e.g., the Internet), and use of aphrodisiacs have enhanced the risks of HIV infections among MSM. Another difficulty in preventing the spreading of the AIDS epidemic is the serious intravenous drug users (IDUs) problem riding high in Russia and many countries in Eastern Europe and Central Asia. Unfortunately their governments did not devise proper countermeasures. These countries are now the few remaining countries where the AIDS epidemic is still spreading prolifically. Regarding drug users as patients instead of criminals could help control the spread of the AIDS epidemic. Another loophole in the campaign to control the AIDS epidemic are the sexually active heterosexual groups, including the adult youth and minor teenage girls in the southern Africa and people engaging in the sex trade in every nation. In Taiwan, HIV/AIDS infection spreads somewhat late; however, its infection rate likewise manifested a gradual annual growth. As of end of July 2015, a total of 30,054 Taiwan nationals had been reported to be HIV infected; the disease had already caused the death of 4,852 people; that is, an average of 6 persons being infected with HIV per day. The problem posed a toll to the society and economy of the nation. In September 2013, the Taipei International Conference on HIV/AIDS, sporting the motto “turning the tide on AIDS starting with me”, hopes to control epidemic through the personal behavior of each person. It is also hoped that people learn to protect themselves, thereby protecting others as well. The seminar especially underscores the importance of “personal responsibility”. Regardless of people being acquainted with HIV/AIDS or living with HIV/AIDS, each person should take on more responsibility in the fight against AIDS. According to the Centers for Disease Control, in the period from 2008 to 2012, three quarters of the men infected with HIV/AIDS acquired the infection through MSM (men who have sex with men). Young people are sexually active, and MSM is the main route of infection in this age group. In the period from 1984 to 2012, the HIV infected people between the ages of 15 and 24 took up 18.5% of the infected population. Ever since, 90% of the HIV/AIDS infection has been acquired through sexual intercourse. Syringe sharing among drug dependents had long been a factor in of HIV infection but the number had remained a single-digit figure until 2003 when, for the first time, the population of syringe-related infections broke the barrier and rose to 74 persons; by June 2007, the number had risen to 5,488 persons, comprising 38.94% of the total infected population. This development indicates the emergence of a new challenge in the gradual growth of the epidemic. Consequently, the Executive Yuan ratified the AIDS Harm Reduction Program to cope with the drastic rise of HIV infection among the drug dependent population. In August of 2005, Taipei City, Taipei County, Taoyuan County, and Tainan County organized the AIDS Harm Reduction Program for Drug Dependents; thereafter, a clean syringe campaign was launched in July 2006. There were 427 syringe sterilization and AIDS health information and counseling stations established throughout 23 cities and counties of Taiwan. In the massive campaign for the use of alternative therapy launched in August 2006, the alternative therapy program implementing facilities established throughout the 22 cities and counties of Taiwan resulted in the significant decrease of AIDS prevalence rate among intravenous drug users; unfortunately, the ratio of new HIV infections reported annually remained to post 15% and above among the male heterosexuals. Furthermore, exchanges between Taiwan and Southeast Asian countries and China having high HIV prevalence rates are quite common, a factor that further hastened the spread of HIV infectionOn November 30, 1990, the Legislative Yuan passed the third reading of the Acquired Immune Deficiency Syndrome Control Act, and on December 17 of the same year, the President decreed its ratification and implementation. In the process of its legislation, the enforcement rules of the bill had undergone a series of amendment before it finally met the society’s requirements. In the yearend of 2001, in an effort to effectively implement the HIV/AIDS control plan, reduce the HIV infections, protect the public health, and preserve the reproductive health of the young generation, thereby preventing the AIDS epidemic from causing any serious social and economic impacts, the Centers for Disease Control of the Ministry of Health and Welfare (formerly the Department of Health) consolidated the resources of all concerned departments and agencies in the implementation and preparation of the necessary countermeasures for the organization of the HIV/AIDS Control Committee (愛滋病防治推動委員會). The move elevated HIV/AIDS control operations to the central inter-agency operations level. To ensure that the government keeps serious attention on HIV/AIDS control operations, the Executive Yuan promised to include the budget for HIV/AIDS control in the priority budget list of the government and to enhance inter-agency coordination and cooperation for an all-out aggressive implementation of control measures and full-scale mitigation of the HIV contagion. Fully understanding the government’s determination in stemming HIV communication, the National Taiwan University Hospital organized the dedicated NTU Hospital staff and medical workers of northern Taiwan for the establishment of the HIV/AIDS Control and Study Center, thereby combating the challenges of the disease through concerted effort and government assistance. Since the establishment of the NTU Hospital HIV/AIDS Control and Study Center in June 1997, the entire NTU hospital staff aggressively participated in the preventive and clinical medicine work, allowing the team to develop greater proficiency. In addition to untiring dedication to the care of hospital patients, NTU Hospital also proactively and aggressively dispatches medical workers to aid other hospitals. For the past 18 years, the HIV/AIDS Control and Study Center, under the full support of the Centers for Diseases Control of the Ministry of Health and Welfare (formerly the Department of Health) has already achieved preliminary results of its efforts. The center was able to reap a wealth of outcomes both in its clinical medical services and research work. Under a stable personnel training and deployment, the center laboratory has reached a certain level of scale and is steadily plodding towards a highly promising and pioneering key phase. We shall continue to shoulder the heavy responsibility of HIV/AIDS control and medical treatment work; in light of which, the center filed an application for the 2015 Annual Program of the HIV/AIDS Control and Study Center with the Centers for Disease Control. Since communication of HIV involves changes in social, cultural, and sexual behaviors, it may be said that the program is a social reform movement in substance and not just a simple medical and health issue. Hence, in addition to AIDS treatment and medical care, the center s hall consolidate the academic, cultural, and social sectors for the concerted implementation of related control programs, with special attention to the education and training. The plan is to employ the existing resources of the center and the respective hospitals in north Taiwan for organizing a series of health orientation classes and seminars, since a widespread disease control education and information promotion campaign is the best way to combat the vicious cycle of HIV communication.We have become quite aware that AIDS is not only a fatal disease, but also a disease that could seriously dent social development, weaken productivity, ward off foreign investments, downgrade the living standards of the nation, and even diminish government and social forces. The entire medical staff of the center will provide people with HIV/AIDS the most suitable antiviral drug and medical treatment for opportunistic infection. Medicine administration regulations are updated every year; moreover, test items and test time intervals are evaluated for the definition of the principles governing test items, thereby equipping clinical physicians with the right materials for reference in the provision of medical care to patients. The center also earnestly endeavors to conserve the health insurance resources and studies more economical treatment procedures for the welfare of HIV patients and enhancement of the medical care system; thus, patients, patients’ families, and their communities may be able to avail of proper support. Nationwide inter-hospital HIV clinical epidemiology related studies were conducted for the upgrade and consolidation of the medical resources and infected people related information of the designated AIDS treatment hospitals in the country. Moreover, assistance was provided in the related clinical epidemiology research, such as, monitoring study of the clinical symptoms of people with HIV/AIDS, prevention and treatment of opportunistic infection, health seeking inclination, high-risk behaviors, and drug resistance and side effects of treatments; results will be provided for the reference of future therapy and control policy making and amendment endeavors. Furthermore, the HIV/AIDS Control and Study Center should take on the role of leading the domestic treatment and control related work and provide the appropriate educational training program for resource planning. Also, the center shall establish and implement Post Exposure Prophylaxis (PEP) procedures. Essentials of the implementation of the 2015 annual program of the HIV/AIDS Control and Study Center are as follows:Study Subject: Integrated Plan for the Control of HIV/AIDS Focal Point of the Study: Applied Research of HIV/AIDS Control Measures, Treatment & Care, and Professional Human Resource Training CoursesStudy Objectives: To develop better medical care and interventional methods for disease control by conducting surveys and analyzing laboratory data of at-risk groups, by performing nation-wide cross-hospital epidemiological studies and treatment /monitoring studies with support of AIDS designated hospitals in the country, by providing training to medical personnel, preventive planning for infected subjects, in order to, ultimately, provide recommendations on integrated HIV care and preventive strategies.Topic 1: Post-exposure Prophylaxis: provide services (such as health education consultation, testing, prophylaxis treatment, follow-up, etc…) and evaluate effectiveness of therapy and promote effective and practical plans for high-risk groups. Topic 2:Conduct domestic research of HIV population: long-term clinical research and monitoring of HIV infected subjects including their clinical characteristics, drug therapy efficacy, side effects, management of opportunistic infections, inclination to seek medical treatment and high-risk behaviors.Topic 3:Analyze HAART drug therapy, prophylaxis, factors related to preventive methods, such as use of condoms among different infected populations in order to improve medical care and develop effective interventional preventive programs.Topic 4:Collect and monitor epidemiology data of HIV infected subjects: co-infections, drug resistance, genetic subtypes, etc… and clinical laboratory data, such as HAART drug blood concentrations. Report resistance surveillance data to Center for Disease Control on a regular basis. Topic 5:Conduct a series of HIV training programs for medical personnel: health education courses (at least 2 courses) and seminars (at least 15 courses) related to HIV care and universal precautions.